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2025 Proposed Rule Aims to Enhance ACA Plan Standards


ACA Plan Standards 2025

CMS Unveils 2025 Proposed Rule to Improve ACA Plans

The Centers for Medicare & Medicaid Services (CMS) has recently released the HHS Notice of Benefit and Payment Parameters (Payment Notice) for the 2025 Proposed Rule. This proposal outlines potential changes to the Affordable Care Act (ACA) marketplaces and requirements for those assisting marketplace consumers.

Advancing Health Equity through Comprehensive Changes

Addressing Health Disparities and Strengthening the Healthcare System

The proposed rule also introduces alterations affecting the Medicaid program, Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP). If adopted, these changes would align with the White House's objectives to advance health equity by addressing health disparities within the healthcare system, as stated in a CMS fact sheet.

Key Proposals to Enhance ACA Plans

Expanding Access and Improving Coverage Building on the Affordable Care Act's principles of expanding access to quality, affordable health coverage, the proposals aim to:

1. Enhance Network Adequacy Standards

Ensuring Robust Provider Access for All Starting from January 1, 2025, CMS proposes that state marketplaces and state-based exchanges enforce network adequacy standards at least as stringent as those required for federal marketplaces in terms of provider access based on time and distance.

2. Include Routine Adult Dental Services

Improving Oral Health and Health Equity CMS aims to eliminate regulatory and coverage barriers, enabling states to include adult dental services as essential health benefits. This change could improve adult oral health and overall health outcomes, contributing to reduced health disparities among marginalized communities.

3. Offer Flexibility in Medicaid Eligibility

Targeted Expansions and Improved Coverage CMS proposes to grant states flexibility in determining income and/or resource disregards for specific individuals within the same Medicaid eligibility group, provided the criteria are reasonable. This approach allows states to target expansions of Medicaid coverage more effectively.

4. Make Minor Updates to Plan Options

Ensuring Actuarial Values Align with Metal Levels Furthermore, CMS plans to allow issuers to offer additional non-standardized plan options beyond the two-plan limit for PY 2025 and subsequent years, provided these plans offer a 25% or greater reduction in cost sharing for chronic and high-cost conditions compared to other non-standardized plan offerings in the same product network type, metal level, and service area.

5. Align Effective Dates of Coverage

Streamlining Consumer Transitions To streamline the consumer experience and prevent coverage gaps during transitions between different marketplaces or other insurance coverage, CMS suggests that consumers who select and enroll in a qualified health plan (QHP) during a special enrollment period receive coverage starting on the first day of the month after selecting a QHP.

6. Establish Marketplace Call Center Standards

Enhancing Consumer Assistance and Information CMS proposes that all marketplace call centers provide consumer access to live call center representatives during published hours of operation. These representatives would assist consumers in applying for a QHP and provide plan information.

7. Set Annual Open Enrollment Periods

Creating Consistency in Enrollment Timing CMS aims to establish a consistent open enrollment period for all marketplaces. For state-run exchanges not using the federal platform, this period would align with the federal exchanges, starting on November 1 and ending no earlier than January 15.

8. Maintain Existing User Fees

Sustaining Support for Marketplace Operations For the 2025 benefit year, CMS suggests maintaining the same user fee rates as in 2024, including a federally-facilitated marketplace user fee rate of 2.2% of total monthly premiums and a state-based Marketplace-Federal Platform user fee rate of 1.8% of total monthly premiums.

9. Recalibrate HHS Risk Adjustment Models

Enhancing Stability and Accuracy CMS proposes using the 2019, 2020, and 2021 enrollee-level EDGE data for recalibrating HHS risk adjustment models. This approach provides stability and reduces volatility in risk scores between benefit years while reflecting recent claims experience.

10. Reduce Risk Adjustment User Fee Managing Costs and Ensuring Fairness For the 2025 benefit year, CMS suggests a risk adjustment user fee of $0.20 per member per month, down from the 2024 rate of $0.21 per member per month. These fees cover various HHS-operated risk adjustment program activities across all states and the District of Columbia.

In conclusion, the 2025 Proposed Rule aims to enhance ACA plan standards, address health disparities, and improve the overall healthcare system.




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